Psychopathy

Psychopathy is a psychological construct,[1] classified by some as a personality disorder, characterized by amoral and antisocial behavior. It is a term derived from the Greek psyche (soul, breath hence mind) and pathos (to suffer), and was once used to denote any form of mental illness, often being confused with psychosis. The term is often used interchangeably with sociopathy[2].

History

Research into a group of individuals he described as psychopathic was first completed by Philippe Pinel almost 200 years ago. Pinel described patients as "insane without delirium," which he characterized as a lack of restraint and remorselessness for their actions. Pinel felt that his patients were morally neutral, reflecting his humanistic approach to mental illness.[3] The 19th century term used for such individuals was "moral imbecile".[4]

The next most distinctive work on what were then called psychopaths was done in 1941 by Hervey Cleckley in his book The Mask of Sanity (significantly expanded in the second edition of 1950). Cleckley offered a broad range of case histories, from all corners of society, all of which showed patients with the common characteristic of "emotional emptiness."[5] Cleckley probed the psychopath's attitudes and thought patterns in search of a meaning for their unusual behaviour; however, according to Robert Hare, Cleckley's most important contribution was in providing the framework of emotion for most future research into this disorder.[6]

Cleckley's characteristics

The seminal 20th century work on the subject is Hervey Cleckley's The Mask of Sanity first published in 1941.[7] In The Mask of Sanity Cleckley introduced sixteen behavioral characteristics of a psychopath that he derived from clinical interviews and other corroborating sources.[8]

Superficial charm and good "intelligence"

Absence of delusions and other signs of irrational thinking

Absence of "nervousness" or psychoneurotic manifestations

Unreliability

Untruthfulness and insincerity

Lack of remorse and shame

Inadequately motivated antisocial behavior

Poor judgment and failure to learn by experience

Pathologic egocentricity and incapacity for love

General poverty in major affective reactions

Specific loss of insight

Unresponsiveness in general interpersonal relations

Fantastic and uninviting behavior with drink and sometimes without

Suicide rarely carried out

Sex life impersonal, trivial, and poorly integrated

Failure to follow any life plan

Some of the criteria have obvious psychodynamic implications, such as a lack of remorse, poor judgment, failure to learn from experience, pathological egocentricity, lack of capacity for love, a general poverty in major affective reactions, and lack of insight into his own condition.[9] Starting in 1972, newer editions of the book reflected a closer alliance with Kernberg's (1984) borderline level of personality organization, specifically defining the structural criteria of the psychopath's identity integration, defensive operations and reality testing.[9]

In summary, Cleckley clearly distinguishes the psychopath from other disorders such as neurotic alcoholics, psychoneurotics, criminal sex offenders and typical criminals. The psychopath does not suffer from any obvious mental disorder. Cleckley characterizes the psychopath as, despite apparent intelligence, seeming to deliberately court failure and disaster for no obvious reason, what Cleckley calls a social and spiritual suicide, or semi-suicide. For example, the classic alcoholic drinks to avoid reality, to escape unpleasant feelings of failure or inferiority, while the psychopath drinks simply to get himself in trouble.[10] Cleckley is very clear that there are important distinctions between the psychopath and the average criminal:[11]

The DSM-III committee, in attempting to develop a trait-oriented basis for the antisocial personality diagnosis, made efforts to combine the work of Lee Robbins's (1966) criteria of behavioral acts with trait items based on the work of Cleckley, as his list of core traits still remains relevant. Robert Hare developed a Psychopathy Checklist based on the psychopath construct developed by Cleckley. Later two items were removed from the checklist in order to more clearly represent the structure of a two-factor analysis.[12]

The label "psychopath" as used by Cleckley had been embraced by popular culture (e.g. Natural Born Killers) and is often applied to the mass sexual killer, and for this reason the imprecise popular use had been deplored. Therefore, although in popular culture the term is common, it had little relevance to criminology, forensic psychology or psychiatry.
[13]

Hare's Checklist

In contemporary research and clinical practice, Robert D. Hare's Psychopathy Checklist-Revised (PCL-R) is a psycho-diagnostic tool commonly used to assess Psychopathy. Because an individual's scores may have important consequences for his or her future the potential for harm if the test is used or administered incorrectly, is considerable, so that the test should only be considered valid if administered by a suitably qualified and experienced clinician under controlled conditions. [14][15]

Hare wants the Diagnostic and Statistical Manual of Mental Disorders to list psychopathy as a unique disorder, saying that psychopathy has no precise equivalent[14] in either the DSM-IV-TR, where it is most strongly correlated with the diagnosis of antisocial personality disorder, or the ICD-10, which has a partly similar condition called dissocial personality disorder. Both organisations view the terms as synonymous. But only a minority of what Hare and his followers would diagnose as psychopaths who are in institutions are violent offenders.[16][17] The manipulative skills of some of the others are valued for providing audacious leadership.[18] It is argued that psychopathy is adaptive in a highly competitive environment, because it gets results for both the individual and the corporations[19][20][21] or, often small political sects that they represent.[22] However, these individuals will often cause long-term harm, both to their co-workers and the organization as a whole, due their manipulative, deceitful, abusive, and often fraudulent behaviour.[23]

Hare describes people he calls psychopaths as "intraspecies predators[24][25] who use charm, manipulation, intimidation, and violence[26][27][28] to control others and to satisfy their own selfish needs. Lacking in conscience and in feelings for others, they take what they want and do as they please, violating social norms and expectations without guilt or remorse".[15] "What is missing, in other words, are the very qualities that allow a human being to live in social harmony."[29]

Current definition

The prototypical psychopath has deficits or deviances in several areas: interpersonal relationships, emotion, and self-control. Psychopaths lack a sense of guilt or remorse for any harm they may have caused others, instead rationalizing the behavior, blaming someone else, or denying it outright.[30] Psychopaths also lack empathy towards others in general, resulting in tactlessness, insensitivity, and contemptuousness. All of this belies their tendency to make a good, likable first impression. Psychopaths have a superficial charm about them, enabled by a willingness to say anything without concern for accuracy or truth. This extends into their pathological lying and willingness to con and manipulate others for personal gain or amusement. The prototypical psychopath's emotions are described as a shallow affect, meaning their overall way of relating is characterized by mere displays of friendliness and other emotion for personal gain; the displayed emotion need not correlate with felt emotion, in other words. Shallow affect also describes the psychopath's tendency for genuine emotion to be short lived and egocentric with an overall cold demeanor. Their behavior is impulsive and irresponsible, often failing to keep a job or defaulting on debts.[30]

Since psychopaths cause harm through their actions, it is assumed that they are not emotionally attached to the people they harm; however, according to the PCL-R Checklist, psychopaths are also careless in the way they treat themselves. They frequently fail to alter their behavior in a way that would prevent them from enduring future discomfort.

Most research studies of psychopaths have taken place among prison populations. This remains a limitation on its applicability to a general population.

It has been shown that punishment and behavior modification techniques do not improve the behavior of what Hare and other followers of this theory call a psychopath. They have been regularly observed to respond to both by becoming more cunning and hiding their behavior better. It has been suggested by them that traditional therapeutic approaches actually make psychopaths if not worse, then far more adept at manipulating others and concealing their behavior. They are generally considered to be not only incurable but also untreatable.[31]

Psychopaths also have a markedly distorted sense of the potential consequences of their actions, not only for others, but also for themselves. They do not, for example, deeply recognize the risk of being caught, disbelieved or injured as a result of their behaviour.

According to Cleckley, such individuals were diagnosed in the psychiatric nomenclature of the United States as a psychopathic personality until 1952 when the term was replaced by sociopathic personality. In 1968, the official terminology was changed to personality disorder, antisocial type. In 1980 the DSM-III changed the term slightly to antisocial personality disorder, a personality disorder being a term that officially includes a variety of maladjusted persons who are not psychotic or mentally impaired.[32]

Legal definition

Psychopathy has quite separate legal and judicial definitions that should not be confused with the medical definition. The American Psychiatric Association is vigorously opposing any non medical or legal definition of what purports to be a medical condition "without regard for scientific and clinical knowledge".[33] The problem with any definition of this personality disorder is that, since deception and deceit is such a fundamental feature of this disorder, a systematic clinical interview must be accompanied by collection of information from various collateral sources.[34] Various states and nations have at various times enacted laws specific to dealing with psychopaths. In the United States approximately twenty states currently have provisions for the involuntary civil commitment for sex offenders or sexual predators, under Sexually violent predator acts, avoiding the use of the term "psychopath". These statutes and provisions are controversial and are being reviewed by the U.S. Supreme Court as a violation of a person's Fourteenth Amendment rights.[35] (See Foucha v. Louisiana for an example.[36])

Washington State Legislature [37] defines a "Psychopathic personality" to mean "the existence in any person of such hereditary, congenital or acquired condition affecting the emotional or volitional rather than the intellectual field and manifested by anomalies of such character as to render satisfactory social adjustment of such person difficult or impossible".[35]

California enacted a psychopathic offender law in 1939[38] that defined a psychopath solely in terms of offenders with a predisposition "to the commission of sexual offenses against children." A 1941 law[39] attempted to further clarify this to the point where anyone examined and found to be psychopathic was to be committed to a state hospital and anyone else was to be sentenced by the courts. However, these laws were enacted years before the American Psychiatric Association began publishing the Diagnostic and Statistical Manual of Mental Disorders which is used today for diagnosis and does not include "psychopathic offender". Hence, these laws are of historical interest only.

In the United Kingdom, "Psychopathic Disorder" is legally defined in the Mental Health Act (UK)[40] as, "a persistent disorder or disability of mind (whether or not including significant impairment of intelligence) which results in abnormally aggressive or seriously irresponsible conduct on the part of the person concerned."

According to Jay Ziskin any diagnosis that does not appear in DSM III is not a formal diagnoses for legal uses, as shown in a quote from Coping with Psychiatric and Psychological Testimony Vol II by Jay Ziskin which is a book for attorneys to shoot down psychiatric testimony in the United States.

One should note whether the report contains a formal diagnosis......Those that do not are weakened......One can usually spot a formal diagnosis by the presence of a code number, usually a three-digit number, sometimes with additional digits ... although in some cases, psychiatrists will state what turns out to be a formal diagnosis without using the code numbers. Where there is a formal diagnosis, one should check to see if it is one of those listed in the diagnostic and statistical manual (DSM-III). .......the lawyer ... should check the manual for the elements required for making that diagnosis and then check to see if the report describes those elements.....If there is a diagnosis, but it is not from DSM-III, this is a matter to be questioned as there is only one official diagnositic classification system and it is DSM-III.[41]

Types of psychopathy

PCL-R Factors

Main article: Psychopathy Checklist-Revised (PCL-R)

The following findings are for research purposes only, and are not used in clinical diagnosis.

Early factor analysis of the PCL-R indicated that it consisted of two factors. [42] Factor 1 capture traits dealing with the interpersonal and affective deficits of psychopathy (e.g. shallow affect, superficial charm, manipulativeness, lack of empathy) whereas Factor 2 dealt with symptoms relating to anti-social behaviour (e.g. criminal versatility, impulsiveness, irresponsibility, poor behaviour controls, juvenile delinquency).[42] The two factors have been found by those following this theory to display different correlates. Factor 1 has been correlated with narcissitic personality disorder[42], low anxiety[42], low empathy [43], low stress reaction [44] and low suicide risk[44] but high scores on scales of achievement[44] and well-being[44]. In contrast, Factor 2 was found to be related to anti-social personality disorder[42], social deviance[42], sensation seeking[42], low socio-economic status [42] and high risk of suicide [44]. The two factors are nonetheless highly correlated[42] and there are strong indications that they do result from a single underlying disorder.[45] However, research has failed to replicate the two-factor model in female samples. [46]

Recent statistical analysis using confirmatory factor analysis by Cooke and Michie [47] indicated a three-factor structure, with those items from factor 2 strictly relating to anti-social behaviour (criminal versatility, juvenile delinquency, revocation of conditional release, early behavioural problems and poor behavioural controls) removed from the final model. The remain items divided into three factors: Arrogant and Deceitful Interpersonal Style, Deficient Affective Experience and Impulsive and Irresponsible Behavioural Style [47]. In the most recent edition of the PCL-R, Hare adds a fourth Antisocial behaviour factor, consisting of those Factor 2 items excluded in the previous model [48]. Again, these models are presumed to be hierarchical with a single unified psychopathy disorder underlying the distinct but correlated factors.[49]

The Primary - Secondary distinction

Primary psychopathy was defined by those following this theory as the root disorder in patients diagnosed with it, whereas secondary psychopathy was defined as an aspect of another psychiatric disorder or social circumstances.[50] Today, primary psychopaths are considered to have mostly Factor 1 traits from the PCL-R (arrogance, callousness, manipulativeness, lying) whereas secondary psychopaths have a majority of Factor 2 traits (impulsivity, boredom proneness, irresponsibility, lack of long-term goals).[51] Secondary psychopaths show normal to above-normal physiological responses to (perceived) potential threats. Their crimes tend to be unplanned and impulsive with little thought of the consequences.[52] Including to those using this theory, this type have hot tempers and are prone to reactive aggression. They experience normal to above-normal levels of anxiety but are nevertheless highly stimulus seeking and have trouble tolerating boredom. Their lifestyle may lead to depression and even suicide.

Mealey uses the term "primary psychopathy" to differentiate between psychopathy that is biological in origin and "secondary psychopathy" that results from a combination of genetic and environmental influences.[53] Lykken prefers sociopathy to describe the latter.

Sellbom and Ben-Porath (2005) describe the distinction succinctly:

Some people who engage in violent behavior possess psychopathic personality traits, such as callousness, grandiosity, and fearlessness, and presumably engage in such conduct because they care little about others. Others are impulsive and experience considerable anger, anxiety, and distress and may commit violent acts as a reaction to negative emotions, which are sometimes referred to as "crimes of passion." Indeed, the distinction between primary and secondary psychopathy (including so-called neurotic psychopathy) has long been noted in the psychopathy literature (Karpman, 1947; Lykken, 1995).[54]

This distinction closely resembles the distinction between instrumental and impulsive/reactive crime/violence in the field of criminology.

Joseph P. Newman et al, who use this concept of psychopathy, have validated David T. Lykken's conceptualization of psychopathy subtypes in relation to Gray's behavioral activation system and behavioral inhibition system.[55] Newman et al. found measures of primary psychopathy to be negatively correlated with Gray's behavioral inhibition system, a construct intended to measure behavioral inhibition from cues of punishment or nonreward.[55] In contrast, measures of secondary psychopathy to be positively correlated with Gray's behavioral activation system, a construct intended to measure sensitivity to cues of behavioral approach.[55]

Diagnostic criteria and PCL-R assessment

In contemporary research and clinical psychiatric practice, the American Psychiatric Association use the DSM and European doctors use the ICD-10 and will use the term antisocial personality disorder. Psychopathy is most commonly assessed by those who subscribe to a separate idea of psychopathy with the PCL-R (Hare, 1991), which is a clinical rating scale with 20 items. Each of the items in the PCL-R is scored on a three-point (0, 1, 2) scale according to two factors. PCL-R Factor 2 is associated with reactive anger, anxiety, increased risk of suicide, criminality, and impulsive violence. PCL-R Factor 1, in contrast, is associated with extroversion and positive affect. Factor 1, the so-called core personality traits of psychopathy, may even be beneficial for the psychopath (in terms of nondeviant social functioning). A psychopath will score high on both factors, whereas someone with APD will score high only on Factor 2.[56]

Both case history and a semi-structured interview are used in the analysis.

The official stance of the American Psychiatric Association as presented in the DSM-IV-TR is that psychopathy and sociopathy are obsolete synonyms for antisocial personality disorder. The World Health Organization takes a similar stance in its ICD-10 by referring to psychopathy, sociopathy, antisocial personality, asocial personality, and amoral personality as synonyms for dissocial personality disorder.

Among laypersons and professionals, there is much confusion about the meanings and differences between psychopathy, sociopathy, antisocial personality disorder, and the ICD-10 diagnosis, dissocial personality disorder.

Sociopathy

The difference between sociopathy and psychopathy, according to Hare, may "reflect the user's views on the origins and determinates of the disorder."[57]

David T. Lykken proposes that psychopathy and sociopathy are two distinct kinds of antisocial personality. He holds that psychopaths are born with temperamental differences such as impulsivity, cortical underarousal, and fearlessness that lead them to risk-seeking behavior and an inability to internalize social norms. Sociopaths, on the other hand, he believes to have relatively normal temperaments; their personality disorder being more an effect of negative sociological factors like parental neglect, delinquent peers, poverty, and extremely low or extremely high intelligence. Both personality disorders are, of course, the result of an interaction between genetic predispositions and environmental factors, but psychopathy leans towards the hereditary whereas sociopathy tends towards the environmental.[51]

Antisocial personality disorder

The criteria for the Antisocial Personality Disorder were derived from the Research Diagnositic Criteria developed by Spitzer, Endicott and Robbins (1978). There was concern in the development of DSM-IV that there was too much emphasis on research data and not enough on the more traditional psychopathic traits such as a lack of empathy, superficial charm, and inflated self appraisal. Field trial data indicated that some of these traits of psychopathy derived from the Psychopathy Checklist developed by Hare et al., 1992, were difficult to assess reliably and thus were not included. Lack of remorse is an example. The antisocial person may express guilt or remorse or offer excuses and rationalizations. However, a history of criminal acts in itself suggests little remorse or guilt.[58]

Comparing psychopathy to antisocial personality disorder is a continuing source of debate. The American Psychiatric Association removed the word "psychopathy" or "psychopathic", and started using the term "Antisocial Personality" to cover the disorder in DSM-II.[59] The World Health Organization's stance in its ICD-10 refers to psychopathy, sociopathy, antisocial personality, asocial personality, and amoral personality as synonyms for dissocial personality disorder.[citation needed]

Hare takes the stance that psychopathy as a syndrome should be considered distinct from the DSM-IV's antisocial personality disorder construct,[60] even though APD and psychopathy were intended to be equivalent in the DSM-IV. However, those who created the DSM-IV felt that there was too much room for subjectivity on the part of clinicians when identifying things like remorse and guilt; therefore, the DSM-IV panel decided to stick to observable behaviour, namely socially deviant behaviours. As a result, the diagnosis of APD is something that the "majority of criminals easily meet."[61] Hare goes further to say that the percentage of incarcerated criminals that meet the requirements of APD is somewhere between 80 to 85 percent, whereas only about 20% of these criminals would qualify for a diagnosis of what Hare's scale considers to be a psychopath.
[62] This twenty percent, according to Hare, accounts for 50 percent of all the most serious crimes committed, including half of all serial and repeat rapists. According to FBI reports, 44 percent of all police officer murders in 1992 were committed by psychopaths.[63]

Another study using the PCL-R to examine the relationship between antisocial behaviour and suicide found that suicide history was strongly correlated to PCL-R Factor 2 (reflecting antisocial deviance) and was not correlated to PCL-R factor 1 (reflecting affective functioning). Given that APD relates to Factor 2, whereas psychopathy relates to both factors, this would confirm Hervey Cleckley's assertion that psychopaths are relatively immune to suicide. People with APD, on the other hand, have a relatively high suicide rate.[64]

Organic brain syndrome

Main article: Phineas Gage

It has been suggested that people can suffer apparently psychopathic personality changes from lesions or damage of the brain's frontal lobe resulting in Organic brain syndrome.[65][66] This is sometimes called pseudopsychopathic personality disorder or frontal lobe disorder caused by physical trauma to the brain.

One well-known and dramatic case was that of Phineas Gage, a 19th century railroad work supervisor, who had been relatively mild-tempered before the damage to his brain occurred. According to Renato M. E. Sabbatini, an explosive charge was set. When it detonated, a steel rod was accidentally driven through Gage's skull from his left cheek to above the right brow.[67] Gage's case is cited as among the first evidence suggesting that damage to the frontal lobes could alter aspects of personality and affect socially appropriate interaction.

Phineas survived for many years. According to the common account[clarify], his personality changed completely. He became abusive, aggressive, deceitful, irresponsible and incapable of insight and planning (a poor sense of consequence). Computerized reconstructions of the brain damage show (in accord with the known site of his brain injury) that he had a lesion in the ventromedial frontal cortex. It is known that damage to the frontal lobes can result in organically caused personality disorders.

However, Malcolm Macmillian's recent research into the Gage case[68] shows evidence that many of the so-called "psychopathic" features were never documented by physician John Harlow, the primary source, or the Harvard physicians who examined him intensively in Boston. No police records or newspaper accounts can be found for Gage's alleged drunken behavior or violence, nor any record of his mother complaining to Dr. Harlow, despite being in contact for years. His personality changes were caused by trauma to the brain.

Childhood precursors

Psychopathy is not normally diagnosed in children or adolescents, and some jurisdictions explicitly forbid diagnosing psychopathy and similar personality disorders in minors. Psychopathic tendencies can sometimes be recognized in childhood or early adolescence and, if recognised, are diagnosed as conduct disorder. It must be stressed that not all children diagnosed with conduct disorder grow up to be psychopaths, or even disordered at all, but these childhood signs are found in significantly higher proportions in psychopaths than in the general population. Conduct disorder, as well as its subcategory Oppositional Defiance Disorder, can sometimes develop into adult psychopathy. However, conduct disorder "fails to capture the emotional, cognitive and interpersonality traits - egocentricity, lack of remorse, empathy or guilt - that are so important in the diagnosis of psychopathy."[69]

Children showing strong psychopathic precursors often appear immune to punishment; nothing seems to modify their undesirable behavior. Consequently parents usually give up, and the behavior worsens.[70]

The following childhood indicators are to be interpreted not as to the type of behavior, but as to its relentless and unvarying occurrence. Not all must be present concurrently, but at least a number of them need to be present over a period of years:

An extended period of bedwetting past the preschool years that is not due to any medical problem.

Cruelty to animals beyond an angry outburst.

Firesetting and other vandalism. Not to be confused with playing with matches, which is not uncommon for preschoolers. This is the deliberate setting of destructive fires with utter disregard for the property and lives of others.

Lying, often without discernible objectives, extending beyond a child's normal impulse not to be punished. Lies that are so extensive that it is often impossible to know lies from truth.

Theft and truancy.

Aggression to peers, not necessarily physical, which can include getting others into trouble or a campaign of psychological torment.

The three indicators—bedwetting, cruelty to animals and firestarting, known as the MacDonald triad—were first described by J.M. MacDonald as indicators of psychopathy.[71] Though the relevance of these indicators to serial murder etiology has since been called into question, they are considered relevant to psychopathy.

The question of whether young children with early indicators of psychopathy respond poorly to intervention compared to conduct disordered children without these traits has only recently been examined in controlled clinical research. The findings from this research are consistent with broader evidence - pointing to poor treatment outcomes.[72]

Discrete taxon vs. continuous dimension

As part of the larger debate on whether personality disorders are distinct from normal personality or extremes on various dimensions of normal personality is the debate on whether psychopathy represents something "qualitatively different" from normal personality or a "continuous dimension" shading from normality into severely psychopathic. Early taxonometric analysis from Harris and colleagues[73] indicated that a discrete category may underlie psychopathy, however this was only found for the behavioural Factor 2 items, indicating that this analysis may be related to Anti-social Personality Disorder rather than psychopathy per se. John Marcus, and Edens more recently performed a series of statistical analysis on previously attained PCL–R and PPI scores and concluded that psychopathy may best be conceptualized as having a "dimensional latent structure" like depression.[74]

In contrast, the PCL–R sets a score of 30 out of 40 for North American male inmates as its cut-off point for a diagnosis of psychopathy, however this is an abitrary cut-off and should not be taken to reflect any sort of underlying structure for the disorder.

Perceptual/emotional recognition deficits

In a 2002 study, David Kosson and Yana Suchy, et al. asked psychopathic inmates to name the emotion expressed on each of 30 faces; compared to controls, psychopaths had a significantly lower rate of accuracy in recognizing disgusted facial affect but a higher rate of accuracy in recognizing anger. Additionally, when "conditions designed to minimize the involvement of left-hemispheric mechanisms" were used, psychopaths had more difficulty accurately identifying emotions. This study did not replicate Blaire, et al. (1997)'s findings that psychopaths are specifically less sensitive to nonverbal cues of fear or distress.[75]

In a 2002 experiment, Mitchell Blair et al. used the Vocal Affect Recognition Test to measure psychopaths' recognition of the emotional intonation given to connotatively neutral words. Psychopaths tended to make more recognition errors than controls with a particularly high rate of error for sad and fearful vocal affect.[76]

A 2004 experiment tested the hypothesis of overselective attention in psychopaths using two forms of the Stroop color-word and picture-word tasks: with color/picture and word separated and with color/picture and word together. They found that in the separated Stroop tasks, psychopaths performed significantly worse than controls; however, on standard Stroop tasks, psychopaths performed equally well as controls.

When split into low-anxious and high-anxious groups, low-anxious psychopaths and low-anxious controls showed less interference on the separated Stroop tasks than their high-anxious counterparts; for low-anxious psychopaths, interference was very nearly zero. They conclude that the inability to integrate contextual cues depends on the cues' relationship to "the deliberately attended, goal-relevant information."[77]